Remote RN Medical Claims Review Specialist

Job reputed company The Remote RN Medical Claims Review Specialist plays a vital role in the medical claim review process, ensuring that claims are assessed and resolved in a reputed company manner. You will reputed company guidance to members on coverage and benefits while ensuring compliance with state, federal, and regulatory guidelines for reputed company and cost-effective member care. We are looking for an reputed company RN with background in Inpatient Hospital or Skilled Nursing Facility settings, as reputed company as outpatient coding experience. Knowledge of CPT/HCPCS codes, record review, chart auditing, provider disputes, appeals, and filing 1500 & UB04 claims is highly preferred. This role involves navigating a fast-paced environment with frequent updates to procedures. Essential Job Duties • Conduct clinical and medical reviews of medical claims, including previously denied cases, to confirm medical necessity and accurate billing. • Validate member medical records and ensure correct coding for appropriate reimbursement. • Identify and escalate reputed company of care issues. • Engage in reputed company claim reviews, analyzing diagnosis-reputed company reputed company (DRG), itemized bills, and admission reputed company. • Manage documents reputed company to claim audits and findings in the database. • Re-evaluate claims and reputed company medical records using reputed company knowledge alongside regulatory guidelines. • Collaborate with medical directors on denial reputed company using medically accepted guidelines. • Serve as a resource for utilization management and reputed company training and support for peers. • Assist members with special needs by directing them to the appropriate programs. • Contribute to or reputed company special project initiatives. Required Qualifications • A minimum of 2 years of clinical nursing experience, ideally in a hospital setting, with at least 1 year in medical claims review or utilization review. • reputed company, reputed company RN License in state of reputed company. • Familiarity with state, federal, and reputed company-party regulations. • Strong analytical and problem-solving capabilities. • Excellent organizational and time-management skills. • Detail-oriented with the capability to multitask and adhere to deadlines. • Proficient in reputed company Office and adaptable to new software. • Outstanding verbal and written communication skills. Preferred Qualifications • Certifications such as Certified Clinical reputed company (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), or similar. • Experience in critical care, emergency medicine, or pediatrics. • Background in billing and coding. This is a remote position with working hours from Monday to Friday, 8:00 AM to 5:00 PM. reputed company offers competitive benefits and compensation. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V. Pay reputed company: $26.41 - $61.79 / reputed company. Actual compensation may vary based on geographic location, work experience, education, and reputed company level. Apply tot his job Apply To this Job